Are There Limits To My Medicare Coverage?
Did you know there are some Original Medicare coverage limits? Medicare covers many of your hospital and medical care costs, but it doesn't cover 100% of them.
Here's what you can do to help bridge the gaps left by Medicare limits and offset some of your healthcare costs.
Original Medicare Covers Medically Necessary Services
Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) cover inpatient hospital and outpatient health care services that are deemed medically necessary. "Medically necessary" can be defined as “services and supplies that are needed to prevent, diagnose, or treat illness, injury, disease, health conditions, or symptoms and that meet accepted standards of medicine.”
As long as the health care services you’re using are covered by Medicare and deemed medically necessary, you can use as many as you need with no Medicare coverage limits on your benefits. But as a Medicare beneficiary, you should be aware of the services that exceed Medicare-approved usage limits.
Benefits With Medicare Coverage Limits
Some Medicare benefits that have annual coverage limits include:
- Extended hospitalization
- Psychiatric hospital stays
- Skilled nursing facility care
- Therapy services
If you require any of these services beyond the annual limits, and don't qualify for an exception, you may be responsible for the full cost of those services for the rest of the year.
Medicare Part A Lifetime Limits
Medicare Part A covers hospital stays for any single illness or injury up to a benefit period of 90 days. If you need to stay in the hospital more than 90 days, you have the option of using your lifetime reserve days, of which the Medicare lifetime limit is 60 days.
Each lifetime reserve comes with a Part A hospital coinsurance payment of $778 in 2022. Once they’re gone, you may be responsible for 100% of your hospital costs.
Mental Health Benefits and Psychiatric Hospital Stays
Medicare only covers 190 days of inpatient care in a psychiatric hospital throughout your lifetime. If you require more than the Medicare-approved stay length at a psychiatric hospital, there’s no lifetime limit for mental health treatment you receive as an inpatient at a general hospital.
Skilled Nursing Facilities
For Medicare to cover skilled nursing facility care, you must be formally admitted to the hospital with a doctor's order. Even so, there are limits to the coverage your Medicare benefits provide.
- Up to 20 days: Medicare pays the full cost
- From day 21-100: you pay a share of the cost ($194.50 coinsurance per day of each benefit period in 2022)
- Beyond 100 days: you pay all costs.
Medicare used to limit the amount of coverage you can get for speech-language pathology services and physical and occupational therapy as an outpatient each year.
Starting in 2019, Medicare no longer limits how much it will pay for medically necessary therapy services. You will typically pay 20% of the Medicare-approved amount for your therapy services, once you have met your Part B deductible for the year.
Medigap Policies Help Offset Medicare Costs
Medicare Supplement Insurance (Medigap) policies are private health care plans designed to supplement your Original Medicare benefits and help pay for some of the out-of-pocket costs that Original Medicare doesn’t cover.